Provider Demographics
NPI:1043285463
Name:DISMUKE, STEWART E (MD, MPH)
Entity Type:Individual
Prefix:
First Name:STEWART
Middle Name:E
Last Name:DISMUKE
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:S. EDWARDS
Other - Middle Name:
Other - Last Name:DISMUKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, MPH
Mailing Address - Street 1:1010 N KANSAS ST
Mailing Address - Street 2:SUITE #3049
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-3124
Mailing Address - Country:US
Mailing Address - Phone:316-293-2620
Mailing Address - Fax:316-293-1882
Practice Address - Street 1:2707 E 21ST ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-2249
Practice Address - Country:US
Practice Address - Phone:316-691-0249
Practice Address - Fax:316-691-9939
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-23530207R00000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1043285463Medicaid
KSB03187Medicare UPIN